John G.T. Augoustides

International evidence-based recommendations on ultrasound-guided vascular access

PurposeTo provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access.MethodsAn international evidence-based consensus provided definitions and recommendations. Medical literature on ultrasound vascular access was reviewed from January 1985 to October 2010. The GRADE and the GRADE-RAND methods were utilised to develop recommendations.ResultsThe recommendations following the conference suggest the advantage of 2D vascular screening prior to cannulation and that real-time ultrasound needle guidance with an in-plane/long-axis technique optimises the probability of needle placement. Ultrasound guidance can be used not only for central venous cannulation but also in peripheral and arterial cannulation. Ultrasound can be used in order to check for immediate and life-threatening complications as well as the catheter’s tip position. Educational courses and training are required to achieve competence and minimal skills when cannulation is performed with ultrasound guidance. A recommendation to create an ultrasound curriculum on vascular access is proposed. This technique allows the reduction of infectious and mechanical complications.ConclusionsThese definitions and recommendations based on a critical evidence review and expert consensus are proposed to assist clinicians in ultrasound-guided vascular access and as a reference for future clinical research.

Randomized Evidence for Reduction of Perioperative Mortality

OBJECTIVE With more than 220 million major surgical procedures performed annually, perioperative interventions leading to even minor mortality reductions would save thousands of lives per year. This international consensus conference aimed to identify all nonsurgical interventions that increase or reduce perioperative mortality as suggested by randomized evidence. DESIGN AND SETTING A web-based international consensus conference. PARTICIPANTS More than 1,000 physicians from 77 countries participated in this web-based consensus conference. INTERVENTIONS Systematic literature searches (MEDLINE/PubMed, June 8, 2011) were used to identify the papers with a statistically significant effect on mortality together with contacts with experts. Interventions were considered eligible for evaluation if they (1) were published in peer-reviewed journals, (2) dealt with a nonsurgical intervention (drug/technique/strategy) in adult patients undergoing surgery, and (3) provided a statistically significant mortality increase or reduction as suggested by a randomized trial or meta-analysis of randomized trials. MEASUREMENTS AND MAIN RESULTS Fourteen interventions that might change perioperative mortality in adult surgery were identified. Interventions that might reduce mortality include chlorhexidine oral rinse, clonidine, insulin, intra-aortic balloon pump, leukodepletion, levosimendan, neuraxial anesthesia, noninvasive respiratory support, hemodynamic optimization, oxygen, selective decontamination of the digestive tract, and volatile anesthetics. In contrast, aprotinin and extended-release metoprolol might increase mortality. CONCLUSIONS Future research and health care funding should be directed toward studying and evaluating these interventions.

Mortality reduction in cardiac anesthesia and intensive care: results of the first International Consensus Conference

There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggesting measures for prioritized future investigation we performed the first International Consensus Conference on this topic. The consensus was a continuous international internet‐based process with a final meeting on 28 June 2010 in Milan at the Vita‐Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons, and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting, and ranking. Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic β‐blockade, early aspirin therapy, the use of pre‐operative intra‐aortic balloon counterpulsation, and referral to high‐volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. This International Consensus Conference has identified the non‐surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra‐aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic β‐blockade, early aspirin therapy, and referral to high‐volume centers. The use of aprotinin and aged red blood cells may result in increased mortality.

Observational study of mortality risk stratification by ischemic presentation in patients with acute type A aortic dissection: the Penn classification

Background Acute type A aortic dissection is a surgical emergency, with an operative mortality as high as 25%. Ischemia is a known predictor of mortality. We tested the efficacy of a classification system—the Penn classification, which is based on ischemic pattern at clinical presentation—to stratify operative mortality risk and identify high-risk groups of patients for further intervention and study.Methods In this prospective observational study, patients underwent a standard aortic dissection repair protocol at the University of Pennsylvania, Philadelphia, PA, from 1993 to 2004. Patients were classified as having no ischemia, branch vessel malperfusion with localized organ ischemia, generalized ischemia with circulatory collapse, with or without cardiac involvement, or a combination of localized and generalized ischemia.Results The cohort comprised 221 patients. The mean age was 61.6 (± 14.8) years and 66.5% were male. At presentation 57.9% of patients had no ischemia, 17.6% had localized ischemia, 15.4% had generalized ischemia, and 9.0% had both localized and generalized ischemia. Overall, 28 (12.7%) patients died during the perioperative period. All-cause mortality differed significantly between groups (no ischemia 3.1%, localized ischemia 25.6%, generalized ischemia 17.6%, combined ischemia 40.0%), yielding an overall 8.3-fold difference for no compared with any ischemia (3.1% versus 25.8%, P = 0.0001). Ischemic presentations together accounted for 85.7% of all deaths.Conclusion The Penn classification of acute type A aortic dissection enabled stratification of patients by operative mortality risk. The system requires further validation, but might facilitate new ways to analyze mortality data for this disorder.

Clinical management of cardiogenic shock associated with prolonged propofol infusion.

This case report details the development of cardiogenic shock after craniotomy in a patient sedated with a propofol infusion. The patient survived with the assistance of extracorporeal membrane oxygenation. A literature review summarizes the syndrome of cardiogenic shock associated with prolonged propofol infusion. This is the first report of survival in this syndrome resulting from mechanical circulatory support.

Anesthesia for Transfemoral Aortic Valve Replacement in North America and Europe

OBJECTIVE The purpose of this study was to determine how the anesthestic approach to transcatheter aortic valve replacement (TAVR) differs in North America and Europe. DESIGN The study was a nonrandomized survey of 82 institutions in North America and Europe performing TAVR procedures. SETTING This was an international multi-institutional survey of medical centers performing TAVR in North America and Europe. PARTICIPANTS Anesthesiologists. INTERVENTIONS Participant anesthesiologists from 82 institutions contacted were asked by telephone and e-mail to describe their anesthetic approach to TAVRs. MEASUREMENTS AND MAIN RESULTS The major finding of interest was if general anesthesia or sedation was used for TAVR cases. CONCLUSIONS General anesthesia is the predominant practice in North America and only 5% use sedation for TAVR cases, whereas sedation is more common in Europe.

Perioperative Management of Pheochromocytoma: Focus on Magnesium, Clevidipine, and Vasopressin

The perioperative management of pheochromocytomas requires meticulous anesthetic care. There has been considerable progress in its management, recently 3 agents that may be particularly advantageous to the anesthetic team have been identified. Magnesium sulfate is readily available, cheap, safe, and effective for hemodynamic control before tumor resection. It has demonstrated efficacy in adults, children, and in rarer scenarios, such as pheochromocytoma resection in pregnancy and in pheochromocytoma crises. Although only recently entering clinical practice, clevidipine exhibits a pharmacologic profile of great interest, showing efficacy in the management of hypertensive crisis and providing rapid titration and precise hemodynamic control. Its application in the perioperative management of pheochromocytoma before tumor resection recently has been described and likely will expand in the near future. Vasopressin has demonstrated utility in the management of catecholamine-resistant shock after tumor resection. A familiarity with these 3 agents offers anesthesia providers further effective pharmacologic options for managing the hemodynamic challenges inherent to this population before and after tumor resection.

Classification of acute type a dissection: focus on clinical presentation and extent §

Recent advances in the management of acute Stanford type A dissection have highlighted the clinical importance of clinical presentation and extent of dissection. The Penn classification of type A clinical presentations is based on ischemic profiles that not only determine mortality but also influence management options. The extent of type A dissection as summarized by the DeBakey classification significantly determines the role of endovascular intervention in this important disease. We propose an integration of these three classifications of acute type A dissection as a framework for future advances in diagnosis, intervention and prognosis.

Advances in Aortic Valve Repair: Focus on Functional Approach, Clinical Outcomes, and Central Role of Echocardiography

The surgical classification of aortic regurgitation (AR) is based on cusp mobility. Based on this classification, there are 3 classes of AR: type I is defined as normal cusp mobility, type II is defined as excessive cusp mobility, and type III is defined as restricted cusp mobility. Patients often have multiple coexisting mechanisms. Because aortic valve (AV) repair is safe, effective, and durable, it likely will become a mainstream surgical option for the management of significant AR, even in the setting of a bicuspid valve. Intraoperative transesophageal echocardiography has a central role at all stages in AV repair. Before cardiopulmonary bypass, it can accurately diagnose the mechanism of AR to guide operative strategy for successful repair. After separation from cardiopulmonary bypass, it can comprehensively evaluate the AV repair, including the likelihood that the repair will be durable in the long-term. Important echocardiographic predictors of a durable AV repair include the absence of AR, cusp coaptation above the annular plane, a coaptation length >4 mm, and an effective cusp height >8 mm. The clinical applicability of AV repair continues to expand and likely will evolve into a mainstream surgical therapy for AR, including minimally invasive techniques.

Rationale, development, implementation, and initial results of a fast track protocol for transfemoral transcatheter aortic valve replacement (TAVR)

The care pathway for patients undergoing transcatheter aortic valve replacement (TAVR), particularly in the US, was initially based on open surgical techniques and often includes general anesthesia, transesophageal echocardiographic monitoring, and cardiothoracic intensive care unit (ICU) stays. Whether a subgroup of patients could benefit from early extubation, fewer days in the ICU, and early ambulation in terms of both cost and effectiveness is unknown.